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Warm Regards

We are still waiting for some answers. I would be glad if health proffesionals from this part of Europe (Central, Eastern) can comment on my question. Often we discuss about the outcomes of clinical trials, however this discussion, which is very important (even critical) for our patients, is missing. Why this trend has been seen?

Firstly, we do not have enough strong patients and payers demands to re-build this health systems in an appropriate way.

Secondly, there aren't supporters of this type of study, which should be supported by the governments and scientists themselves.

Thirdly, the cooperation among healt care proffesionals (primary physicians, clinical pharmacist, outpatient pharmacist and nurses) is not a kind of teamwork, which is seen often only on the papers.

Fourthly, the bills for inappropriate prescribing is still very low for the hospitals, because patients do not use the right law to protect themself from being treated with an inappropriate medication.

If I sum up, i see that these mistakes are critical (major, X mistakes) in these health systems and teamwork communication should be established more often. Why almost we do not have trials about inappropriate prescribing from these countries? If there are no reports it is hard to say, however they should be done in near future to protect patients from being treted with the inappropriate medications.

In addition I have some important questions:

- If there are clinical pharmacist or even pharmacologist to check the correctness of prescribing drugs (dose, indication, DDIs, clear prescribing on the chart (paper chart).

- Is a communication between prescribers and clinical pharmacist established before patient is treated with prescribed medicines (all questions and mistakes should be solved BEFORE first application to the patients).

- If the clinical pharmacist or even pharmacologist are included in the wards' rounds every day and morning reports.

- If there is data available how often are patients treated with inappropriate medications within hospitals (clinical pharmacist should conduct these studies/trials).

- If there is a policy how medications should be delivered and clinical pharmacists check the nurses, when medications are administrated to the patients.

Because in many countries clinical pharmacists of even hospital pharmacist just stay in their offices and pharmacies, which is one of the biggest mistake of healt systems in those countries.

Clinical Pharmacy (CP) has not still been recognized as an necessary tool to achieve optimal treatment outcome. Firstly, it has not been recognized by the Government and Ministry of Health, which should provide action plan how to implement CP in secondary and tertiary healthcare. Honestly, I don't think they even seen a need for that. Secondly, it has not been seen as healthcare profession by medical school, responsible for education of medical doctors (MDs). It is not presented as a help to their routine job. Even pharmacist think do not understand the CP. They think it is more control of MDs, less help with the same goal. However, MDs are often worried about prescribing and decision make, but we should make a difference between prescribing and conducting and providing a therapy. MD should prescribe, but PharmD should provide and conduct. Even there is no prescribing errors, there is a lot of work to do with the patients at the hospitals and clinics. 

So, legal frame for implementation in healthcare system, education of MDs and dentists about their existence and knowledge, but as first of all, appropriate education of pharmacist to be eligible with a full competence. 

Nikola Stefanovic many thanks for your fine answer. I understand You BCS i have been involved in the enrolling of clinical pharmacy service in Slovenia, before many years. How to start is very important and You have many nice policies (e.g. Chinese policy) and You can choose between soft (Chinese) or aggressive way (Australian, Canadian in last time). At the moment we are very strong in this part of Europe and we have the place inside primary community settings, where family practitioners can send the patients to our service every week within the same setting (usually one clinical pharmacist for 8 hours in each primary setting weekly), especially BCS of adverse events, polypharmacy, treatment adherence and other questions. Also in Slovenian hospitals we are very important in some of them, because we deal with patients every day next to the patients' beds.

To work with MDs it is easier If you are strong in medical research (e.g. polypharmacy, inappropriate prescribing, DDIs, drug adherence) and most important outcomes' research. Outcomes are the most important and If we can conduct those trials and the results are positive (e.g. better results in Hamilton's score in patients with the major depressive disorder after 6 weeks) it is perfect. However, the most important is how to measure our effect and therefore excellent knowledge is necessary (e.g. how to measure clinical effects, treatment goals, etiology of disease, epidemiology and of course pharmacotherapy). In addition, we should work with the patients and we share the common patients with MDs andif the results are better for all of us and of course for patients and payers (for what we are paid) it is wonderful, although this process from supplier to provide (decision maker) is not very easy, because health system has not been updated in this way.

In addition, to become a reviewer in famous journals within medicine, psychiatry etc ...  is step forward great results and to teach clinical pharmacy we need teachers from real clinical practice with scientific results, which is not very easy and still we do not have many of them.

I think You should try to make good plan how to promote clinical pharmacy services within Serbian hospitals. Undoubtedly is clear that patients and payers support this way of teamwork.

Regards,

Matej

Thank you for your suggestions. We are on the way of the implementation. Everybody experience is always welcome.  

Sincerely,

Nikola

First, it seems necessary to define the "inappropriate" prescription. Is it an error in the dosis, or in the name of the drig; or is it a difference between the prescribed treatment and the "gold standart" or the Evidence Based  medicine? In the first case a control of the parmacologist or pharmacist may be useful if it is systematic. But I wonder wether it is possible and how. In the second case the control of the physician by a person who is a specialist but not a clinicist (unless this person may hace access to all the medical documents) is little pertinent. Moreover it may be dangerous, as far as treatments must be individual and a part of patients do not correspond to the statistics whuch are the basis of the "studies". But a sevice of clinical pharmazcomogy as a reference, a consultant, a help for physicians would be welcome and very useful.

As to the peculiarities of East Europe medicine, it is necessary to understand the traditions and the conditions of its services before criticizing....

The data presented represent the reality, including in Brazil, unfortunately. I believe many pharmacists despite a lot of investment, are not prepared to take the clinical pharmacy and dealing with conflicts of interest between doctors and industry direction. For the completion of the clinical pharmacy, the hospital's senior management must support this process, as well as hire more pharmacists to enlarge the activity and gives continuity to the process. Patients and family members support the initiative and seek this service. The pharmacist must be prepared to face the questions doctors, after an intervention on drug interaction suggesting change in prescribing certain medicine, doctors want the pharmacist suggest what medicine then prescribe on the frame.

Many thanks to all for a nice discussion, which has been seen on this topic. As one of the surveyers for international acccreditation system for the hospitals (my field is a medication management) I see this problem as one of the biggest in these parts of Europe, where clinical pharmacy (CP) or even pharmacology service has not been established. In these countries we do not have quality data about medication mistakes and treatment failure. If You do not believe check in MEDLINE/Pubmed. Dear Véry Coulic I understand your concerns about CP service, however i am sure that You are not sure what a clinical pharmacy is (see my clinical cases on my profile with direct patient care). In these countries, where CP has not been established I see as surveyor many opposite opinion about CP and people often think (some nurses, physicians, politicians) this is not necessary (we do not need this, we do not make mistakes, mistakes are small, patients are different, guidelines are guidelines, we do not have enough staff, patients are treated in a appropriate way). However, after a brief review of the hospitals and their documentation I still (with my colleagues MDs from U.S, which are also part of the review process) see many mistakes. And those mistakes are often critical (X value).

For example in one psychiatric hospital we found the following important mistakes: (clinical pharmacist do not know to which patient are dispensed medicals, antibiotic use has not been seen in the patients' charts, no reports about adverse events, no discussion and plan how to avoid inappropriate prescribing, admission problems with drugs, no medication reconciliation, no evidence in medication why drug was titrated up, inadequate respect to treatment guidelines, serious and even contraindicated drug-drug interactions, no drug history process done by pharmacist, no data in the  patients' chart why antipsychotic polypharmacy was used instead of monotherapy immediately, no data how medication should be given to the patient by nurses, for many important drugs (e.g. quetiapine SR, haloperidol, ciprofloxacin) no data how they should be taken, no pharmaceutical care next to the patients' beds, missing doses (e.g. usually the lowest dose then is used, however this can have impact on patient survival in the case of rivaroxaban) of rivaroxaban, no antibiotic switching form I.V. to tablets, no sound-like and look-like medication systems, many discontinuations with pharmacotherapy without evidence (patient took at home rivaroxaban but at admission did not continue, duloxetine used together with ciprofloxacin, inadequate treatment outcome determination (no Hamilton's scale, PANSS etc ... ).

After this review we cannot say that there are no medication-related problems (DRPs) in this hospital. In addition, many mistakes are critical for the patients safety (case by missing daily intake of methotrexate instead weekly) and better clinical outcomes (case by missing dose of rivaroxaban) and brief team-evidence based (not eminence-based) discussion should be established to improve the patients' outcomes (safety and efficacy). The most important in risk assessment, which has not been done in this hospital. Very qualified clinical pharmacist (PharmD., BCPS) with clinical experience would be the most valuable profile for this hospital and also cost-effective (every 1 USD for clinical pharmacist is always pays back for 3-5 USD). 

It is easy to say: we do not have the adverse events, because we are very good and we do not prescribe any inappropriate medicines, because we know the guidelines. According to the data this is not true, for example in psychiatry more than 30 % of psychiatrists do not respect their guidelines for antipsychotic polypharmacy. More than 40 % of antibiotics are not prescribed according to the guidelines and more than 10-20% of patients for chronic heart failure are not treated with the most effective treatment combinations (e.g. beta blockers, ACE). More than 10 % of the patients are admitted to the hospitals BCS of inappropriate prescribing. The total cost of our mistakes is more billions.

Firstly, risk assessment in each hospital should be done and after action plan according to the risks in each hospital should be done. Secondly, quality Indicators should be established in each hospitals. Thirdly, a brief analysis should be done and corrections established. Fourthly, a discussion in a evidence-based medicine way should be established after and case-by-case team discussion. In many hosptitals unfortunately we still do not have this opinion. However, we should improve ourselfs and these studies are needed to improve immediate situations in many European hospitals. If we want to make a step towards quality we should have our own data for each hospitals. 

In god we trust, all others must bring data:) Do not forget .. Together we are stronger!

I think the biggest barrier to implement and develop CP in eastern european countries is how to measure clinical pharmacist outcomes translate into costs and present to be acceptable. 

Firstly, it is difficult to note mistake or some pharmacotherapy problem at the clinic , which could be prevented by clinical pharmacist, without clinical pharmacist at the clinic. Who will do that instead? Problems may never go out from the clinic, money will be spent on solving it. Will management of the hospitals let pharmacist to conduct this kind of survey? However, if this problem as prescribing error or wrong advice come out the clinic and prescription and patients come to community pharmacy, it can be noted. Still, community pharmacist should be stimulated to note them i check in them. 

Secondly, national strategy is needed for that or at least pharmaceutical chamber (independent pharmaceutic association) should provide action plane with adequate database, where you can describe potential problem or exposed. 

Without government based plan to put some clinical pharmacist on duty with the periodical reports about their work, the path is questionable. I think it is easier to copy results of the studies from the countries with more developed healthcare system. 

Dear Nikola,

You are right, especially with the last paragraph. The most important is that you have 'fighters' among clinical pharmacists, who are well prepared for clinical environment, which is much more difficult thank faculty environment. In many Eastern European hospitals (as i saw as surveyor for medication management) there is still no case-by-case discussion every day (or very rare) within the team on the wards (pharmacist-physician-nurse-patient). Even patients' charts are not checked by clinical pharmacists and/or clinical pharmacologist (therapy from colleague is not changed often, although is necessary). I think this is very big mistake and play a crucial role in the medication mistakes. 

My opinion is that You should conduct a trial (supported by government) and you calculate how much cost these interventions and what was done (avoid serious mistakes and harms). When you do this, you should publish this trial and further discussion within hospitals' teams is needed. The most important is evidence about clinical pharmacists' interventions and appropriate discussion within the team (in real clinical practice it is not very easy often). Every intervention should be documented and also consequences (accepted by physicians or not). After it is easy to calculate from data and published trials. However, we should not forget we do it because of the patients first (not nurses, directors etc ... ). You can also ask the patients If they want more informations about their drugs and medication adherence and of course If they want to enter in to the collaborative care with clinical pharmacist.

In addition the pharmacist (patients) usually do not have their training within departments with patients. You should 'build' a new specialization from clinical pharmacy (3-4 years) in which all clinical pharmacists will work with physicians and nurses next to the patients' beds (this is very important). Without patients' beds you cannot work as clinical pharmacist and therefore a mental and knowledge shift from dispenser to provider is necessary.

Another additional option is an international accreditation system for the hospitals (e.g. American AACI), where there is strong clinical pharmacy (this is necessary in all EU-hospitals). If the surveyors will be from U.S. or European surveyors there will be many questions about clinical pharmacy actions within the wards. This is very helpful in accepting this action in real clinical practice.

Regards,

Mathew

Medical doctors, specialized in Clinical Pharmacology.  "even clinical pharmacologist" what should this mean?

Medical doctors, specialized in Clinical Pharmacology = clinical pharmacologist

Doctor of pharmacy (Pharm.D.), specialized in Clinical Pharmacy = clinical pharmacists

Clinical pharmacists work directly with physicians, other health professionals, and patients to ensure that the medications prescribed for patients contribute to the best possible health outcomes. Clinical pharmacists practice in health care settings where they have frequent and regular interactions with physicians and other health professionals, contributing to better coordination of care. The clinical pharmacist is educated and trained in direct patient care environments, including medical centers, clinics, and a variety of other health care settings. Clinical pharmacists are frequently granted patient care privileges by collaborating physicians and/or health systems that allow them to perform a full range of medication decision-making functions as part of the patient’s health care team. These privileges are granted on the basis of the clinical pharmacist’s demonstrated knowledge of medication therapy and record of clinical experience. This specialized knowledge and clinical experience is usually gained through residency training and specialist board certification.

For more info please see the following web:

https://www.accp.com/about/clinicalpharmacists.aspx

Mrs Lana Nezić who deal with inappropriate prescribing in your country? You have special action plans within the hospitals? Who check the prescribed pharmacotherapy and clinical pharmacist check the pharmacotherapy BEFORE drug dispensing? Are the nurses checked when the medications are administered to the patients? Have Your hospitals appropriate strategy how to prevent serious medical events and harms to the patients?Is a risk assessment done within this field in each hospitals? Are serious events reported and education is established to improve next prescribing?

I MEDLINE i didn't find any appropriate article about that in your country.

Dear Matej Stuhec

I agree with you and with many of the exposed answers, in the sense that budget, infrastructure, organization and trained personnel required to monitor prescriptions, especially those that take place in the (primary care hospitals and medical units specialty). Preferably if apart from the economic contribution plan, such activities are supported or covered by a Law of Health or Health, or at least a program and regulation to support a strategic and operational plan, as part of the quality health care that a certain population is provided, to ensure effectiveness, efficiency and quality. We did not have this service or staff in most European medical units, I believe that if a deficiency that will somehow have to solve.

It is true that one percent of prescriptions are inadequate, but fortunately are not very significant, and even some of them can be considered as an acceptable standard of "medical error" to identify susceptible to train personnel who commits it.

Another way of undesirable effects of prescriptions not because these are inadequate, but the inherent undesirable effect of medicines or also called adverse reactions, which depend in most cases of anatomical and functional characteristics of patients or even , the condition or disease grounds of prescription.

In Mexico, the Mexican Social Security Institute (IMSS) we have an organization at the central level or senior management to operational level medical units, where doctors are responsible for prescribing and monitoring (medical indications) and nurses, which apply in practice the requirements and manage them.

Within each medical unit of the IMSS (mostly hospitals) have departments are responsible for identifying and improving the quality of care, with many medical and health activities, including the requirements and identification of adverse drug reactions ( RAM) same as those recorded in specific formats for retro-inform staff of the unit, in order to improve requirements and develop training programs, and on the other, these records Institutional drug-monitoring unit are sent to operation information system (quality indicators of care) and to plan staff training to nacidonal level (Mexico) in a program called "Reasoned Prescription" which has implications both in quality programs of the institution, as the best use of resources, including financial.

Operationally, this function improved prescribing, develops own health personnel in charge of direct patient care (doctors and nurses). In each medical unit has annexed a service pharmacy, dispensing drugs, and in every emergency room, ICU and Hospital, there is a temporary storage center for the daily administration of prescriptions.

Finally, I agree that incorporate staff training as a pharmacist and / or clinical pharmacist, which would be useful to improve the quality of prescriptions, thus reducing the inappropriate prescriptions, medical error and adverse reactions.

In Mexico there is already the career of Clinical Pharmacy (It began in the city of Cuernavaca in the state of Morelos), graduates gradually being incorporated as workers in the area of health in the country's institutions (IMSSS, ISSSTE, for example ).

Best regards

Sincerely

Dr. Jose Luis Garcia Vigil

PS: These actions pharmacovigilance are posted on my profile, the "contributions" item from a server.

Dear Dr. José Luis García Vigil,

I agree with You, especially with the first paragraph. This mistake of the development or/and formation of many European countries' health systems should be corrected as soon as possible, otherwise the patients should be establish their own way, which will be very expensive for all of us (in the U.S. one fatal mistake is covered by enormous funding, one inappropriate prescription about 100.000 USD). On the another hand, it is true that many mistakes are very important and many adverse events (ADR) are serious. More than 70 % of ADR are preventable and therefore a brief discussion among prescribers and pharmacists and nurses should be established. In many countries, where there is a big lack of clinical pharmacists (most EU countries), there are many medical errors, mistakes and ADR, although they are often not reported. According to the (Bond et al. 2005, Pharmacotherapy) there is about 50 % total decrease in the number of medical errors, if clinical pharmacy service is established within the hospitals. Another important thin is to establish clinical pharmacy pharmaceutical care next to the patients' beds, which is very important for clinical outcomes. As a surveyor from medication management process i saw many European hospital, where pharmaceutical care have not been established within the departments (next to the patients' beds). After a brief review i was surprised that in many EU hospitals there is no place for pharmaceutical care. After my question there were many answers: ' we do not need this'. However, after a brief review they saw that this is very important for better clinical outcomes and patients' safety (e.g. who teach the patients how to improve adherence to the medications, who teach the patients about the ADE and who measure the clinical outcomes together with prescribers).

Many hospitals do not have appropriate risk assessment within this field, nor they have plans how are their patients protected from being treated with inappropriate medications. If I sum up, please do not forget, together we are stronger than alone!

Regards,

Dr. Matej Stuhec, Pharm.D.

Agree that the situation would be better if they work in a coordinated clinical pharmacist and doctor, both in care at the bedside of patients in hospitals, and the training of students in careers in medicine and clinical pharmacy.

As the field of medical errors, adverse drug reactions and inappropriate prescriptions, each are separate fields, but often may be related and have fields in common, way of overlaps in the diagrams of Ven.

Another issue to consider is the great under-reporting of such activities there and reactions.

Best regards

Sincerely

Dr Jose Luis Garcia Vigil

Specialist in Internal Medicine and Professor of Medicine Pharmacovigilance Expert

I again agree with You, especially your first paragraph. Clinical pharmacists (Pharm.D.) and physicians (M.D.). should work together next to the patients' beds. We have many evidence that collaborative care is better as work alone. This should be generalize to health systems worldwide (J Am Heart Assoc. 2014 Apr 10;3(2):e000718; Eur Heart J. 2012 Feb;33(3):314-24.).

Next question is how to implement these health systems, where there is a big lack (South-Easter Europe, Ex-Yugoslavian countries etc ... ). Therefore the main aim of my question was to ask health professionals (pharmacists, physicians) about their opinion.

There are two important issues:

- how to move up from tradicional pharmacists' work in pharmacy (drug dispensing) to clinical pharmacy (measure and define clinical outcomes together with physicians, patients' care, meta-analysis, clinical trials, drug adherence, medication management, medication reconciliation). How to give the right answers at right time next to the patients' beds. With this also comes the increased responsibility in case of medical errors (shared responsibility).

- how to accept collaborative care next to the patients' beds after so many years of working alone (traditional only physicians-nurses, which is seen in many EU countries). This is very important step and a key step if we want a collaborative care (accept clinical pharmacist next to the patients' beds, clinical pharmacists at medical rounds within the wards, established communication before drug dispensing between clinical pharmacist and physician, accept answers with EBM support, accept pharmaceutical care next to the patients' beds).

This is not very easy step and usually it takes so much time to do it. However, the patients and payers support collaborative care as it seen in many countries worldwide. I think this part of Europe should move up towards this field (sooner better for the patients). As a surveyor in this part of Europe i saw so many medical errors and inappropriate prescribing on the patients' charts (not checked by clinical pharmacists) and also mistakes in the drug administration process (usually done by nurses). Often i saw that a communication (no-communication, bad communication, no EBM discussion on case-by-case basis) among healthcare professionals was the main reason for errors, which is very sad. Second reason was an absence of medication management program within the hospitals without appropriate risk assessment plans within this process (who check, how to react, how to solve). Many hospital directors even didn't know how many adverse reactions have been reported to the agencies, how are patient protected from medical errors and how many medical complications they solved.

Regards,

Matej Stuhec, Pharm.D., Ph.D.,

Psychiatric Clinical Pharmacist Consultant

Matej,

there is many ways to change a roll of the pharmacist, from dispensing to patient, but I think the right way is through education process and good course of specialization in clinical pharmacy. As I said before, the health policy should be prone to employ pharmacist at the clinics, not to work at the hospital pharmacy, but to be next to the patients bed. This education, I am mentioning should, should be consisted at least of 3 years postgraduate, which can be combined with PhD studies, such as seen in USA and it is appropriate in this field (it is young medical and pharmacy discipline). Also, it is thin line between science and practice, when we speak about clinical pharmacy and their contribution to clinical practice and health system. Besides I think that these pharmacist, PharmD pharmacist will be recognizable by MDs. 

Second issue, I am strongly agreed to you. And again it can changed if education of MDs and nurses is changed parallel with education of pharmacists. 

Exp. If I have some pharmacotherapy problem. (P) contraindication (gout and thiazides) Cause (C) wrong medicine to initiate antihypertensive therapy, Intervention should be, patient counselling and return the patient and prescription to the prescriber with some comment. 

Still, he or she (MD) does not know about your presence and your knowledge and your obligation to the patient. He or she still believe you should only do dispensing.

However, it they (MD and nurses) learn about clinical pharmacist and how can they use them (through undergraduate studies) and be aware of their curriculum = collaboration.

MDs should learn only one simple thing: they should prescribe (with or without consultation with CP), but pharmacist conduct the therapy, which includes a lot, but the base is medication management and patient counselling. 

But, what if MD do not accept our opinion and advice about chosen drug, dose,...?

Regards,

Nikola Stefanovic, Ph.D

teaching assistant at Clinical pharmacy and Pharmacokinetics

Department of Pharmacy, Faculty of Medicine, University of Nis, Nis, Serbia

The pharmacy profession is evolving in many developed countries, and there is steadfast transformation of pharmacy profession from the pure dispensing role to the patient centered multi-disciplinary care giver role.

As far as the question of implementing and appointing the pharmacists in clinical role (it can be either pharmacists with clinical rotation or clinical pharmacists ), but certainly not M.D Pharmacologists (basic medical doctors with masters in clinical pharmacology) as some readers mentioned,there are very few of them even in developed countries.

Its is very vital to convince the stake holders (hospital administrators,medical directors,hospital entrepreneurs,human resources,finance etc.,) with evidence based studies that will enlighten them and satisfy them by appointing pharmacists/clinical pharmacists will result in minimizing the  morbidity and as well as better outcomes,length of stay,lesser ADR,better medication management and usage  and so on and so forth.

Dear Nikola,

I agree with You. Clinical pharmacy process should be supported by government, however it is not easy in real clinical practice (although you have a support from them), because team (mainly physicians and nurses) should accept them next to the patients in a parallel way until the best clinical outcomes. There will be many health professionals against clinical pharmacists next to the patients' beds and consequently you need strong clinical pharmacist (very strong in communication especially). Another thing is a acceptance rate. According to the published data the acceptance rate by prescriber is high (70-95%) in many trials, although to establish this communication is not easy. Firstly, all interventions by clinical pharmacists should be written. Secondly, all interventions by clinical pharmacist should be implemented by easy question: accept, do not accept. Thirdly, If You use patients' chart (paper one) add additional space with clinical pharmacy name under the prescribed medication. You can check prescribed medication every day and make signature under the prescribed medications (in this case you know which patients is treated with which medication and/or their combination). If You use electronic program is even easier to check.

Very important is to give the prescriber's feedback at each interventions. Many mistakes we did, bcs we didn't communicate with prescribers very often and very well. Before administrating there should be clear which medications are prescribed to which patients in a CLEAR way (dosage, name of the drug, form etc ...).

After you have reviewed your work you can publish and present your work to the hospitals' owners, government, MDs, Pharm.Ds etc ...

Dear Sultan,

I also agree with you. Clinical pharmacologists cannot substitute clinical pharmacists, although many healthcare professionals do not know the difference between those two jobs. However, the situation for clinical pharmacologists was much easier, because they are MDs in many European country (e.g. Croatia, Serbia I dont know Nicola can add), because MDs were better accepted by MDs (their colleagues). After this system has been established it was even harder to establis clinical pharmacy, because small 'fight' was on the way.

According to the recent data and my clinical experience clinical pharmacologists also cannot substitute clinical pharmacists. The same situation is seen also in U.S., where there are many clinical pharmacists prescribers and almost no clinical pharmacologists. The bigger difference is a pharmaceutical clinical care (all activities within this field), which can get us better clinical outcomes (collaborative care). Additional knowledge of cost-effectiveness trials (health economics), clinical trials and epidemiology (how frequent is one medical error and DDIs), time to death trials, drug adherence, over the counter medications and EBM decisions are very beneficial for clinical pharmacists. In these countries, where clinical pharmacology exists, there is also a place for cooperation and it should be established as soon is possible.

In addition, as surveyor from medication management i saw a big opposition against clinical pharmacy in many hospitals in Eastern Europe, when i asked the leadership why they do not cooperate with hospital pharmacist even better. After the survey has been completed and I added remarks from this field there were no questions anymore why clinical pharmacists are necessary in hospitals (I gave some practical examples in my writing before).

I still wait clinical pharmacologists from Eastern and South Europe to comment on this topic (e.g. Serbia, Croatia, Bosnia, Romania, Bulgaria etc ... ). One small comment was from Bosnia, however the main topic was not commented.

Regards

It is difficult to implement all the above mentioned, in particular the implementation of a well-organized system where there is collaboration with the patients bed clinician (which essentially is or should be an expert in clinical pharmacology and therapeutics to be officially authorized prescription) and clinical pharmacologist.

The first step has already been taken, in the sense of accepting the need to work in coordination in the same clinical, medical and pharmaceutical field.

Second align this need with a diagnosis of training needs of such professionals in the countries where it still has not been made this reflection.

Third convince the legislative and executive authorities of the ministry of the country concerned, to create or update laws that allow better linkages in the labor market both the physician and pharmacist, that is, balance supply (schools and colleges higher education in health) - demand (health institutions of the country where these professionals work.

Fourth and finally, update or create curriculum of doctors and pharmacists and develop appropriate plans and programs of study which will build and develop the necessary skills for their professional profile and collaborative work in the field of reality, once trained, graduates.

I insist that the road or path is not easy if you have not worked on the matter: Laws and regulations ---> budgets, money -------> ------- infrastructure development> Market Research Work ---------> Curriculum, plans and programs of study.

In any given moment you have to start this way.

To paraphrase a popular song from my country, I could add "no walking path, the path is made by walking and walking and walking .....".

Sincerely

Dr. Jose Luis Garcia Vigil

Thanks to all of you! This is very nice discussion as it can be seen from the number of posts! We move forward our discussion!

It is clear that is much easier to promote clinical pharmacy, where clinical pharmacology actually does not exist next to the patients' beds (as is also the same in my country Slovenia). Where this cooperation has already been established and works very well, there is very difficult to establish clinical pharmacy service next to the patients' bed. However, cases and mechanism as it has been seen in U.S. clearly demonstrated that this is possible! 20 years ago there were almost no clinical pharmacists in health system in U.S., although they had clinical pharmacologists. On the other side, in 2014 there were almost 5-7 fold bigger the number of CP than clinical pharmacologists and their position within the U.S. system is much more important next to the patients' beds in the hospitals and primary community settings (specialization from ambulatory clinical pharmacy also exists in U.S. approved by AACP; https://www.accp.com/). In many countries within U.S. they have prescribing rights.

25-30 year ago prof. Stimmel (clinical pharmacist) from University of Los Angeles had received funding for research within this field (better prescriber is clinician or clinical pharmacist). He (with his colleagues) published many papers on this topic, which had been supported by government of California. These results were surprisingly better or even the same that the results of clinicians (Drug Intell Clin Pharm. 1981 Sep;15(9):665-72.; Am J Hosp Pharm. 1983 Aug;40(8):1343-4.; Forum Med. 1980 Jun;3(6):404-5.; Am J Hosp Pharm. 1982 Sep;39(9):1483-6.).

After these results California government and insurance companies have clinical pharmacists possibility to prescribe medications. From first specialists within clinical pharmacy approved by AACP in 1980 or even before now is more than 10.000 clinical pharmacists specialists available within the U.S. 

In addition, we should establish a collaborative care from students (students from pharmacy, pharmacology, medicine, nursing should work together within studying and their systems with the same patients and real clinical problems based on case-by-case basis). Anyway, if we have trials from which is obvious that we get 5 USD from 1 USD paid for clinical pharmacist, we should move forward this process.

In these countries, where clinical pharmacology already has been established next to the patient's bed it is necessary to conduct clinical trials and pharmacoeconomic analyses, which show important results also for payers. Well done prepared and teached clinical pharmacist with a knowledge from meta-analyses, treatment guidelines, pharmacokinetics, pharmacoeconomics, plants, drug administration rules and risk assessments, epidemiology, real drug-drug interactions, etiology of diseases will be very helpful for health team, although clinical pharmacology is established.

Regards

I think your question is very fair and professional set! The presence of a clinical pharmacologist or pharmacist for help in transcription fair treatment and avoidance of polypharmacy, which brings with it an increased possibility of adverse consequences. I have tried and largely failed to make contact as a professor of clinical pharmacology at the Medical Faculty in Tuzla with fellow clinicians in UKC Tuzla!

 I went to meet with them and copied together therapy and in rounds, discussed with all aspects and all do together to avoid polypharmacy and give medicine to extend for at least side effects!

This cooperation was for mutual satisfaction and us who treat patients pharmacologist - medikus clinicians and patients dibijali best treatment in our opinion at that point!

Also, I have thus raised and directed the young colleagues who specialize Clinical Immunology that should establish close contact with clinicians and together raditi.mislim that I have largely succeeded in the period 1993-2002 while working in Tuzla Medical Faculty, as Safe , and the Institute for katerdre farmakologiju.to was not easy because in this period to 1995 led the bloody war in Bosnia and Herzegovina as we additionally difficult working conditions!

 I have responded to other centers in Bosnia and Herzegovina, because enough not know the situation in them! In touch with colleagues that I have not enough information promoted this aspect of the organization of a multidisciplinary approach pharmacologists-pharmacists and clinicians what is best resolved to avoid polypharmacy!

I am glad that You are interesting in collaborative care models. Absolutely clinical pharmacist and pharmacologist should cooperate in this important issues. Polypharmacy is a big problem, although not only problems where clinical pharmacists should be included. A pharmaceutical care which should be established within each hospital ward is one of the most powerful steps towards better clinical outcomes. On daily basis this discussion should be involved on the ward among different specialists to find the most appropriate solution for each patients. This discussion should be supported by evidence based medicine (nor eminence-based), where errors are recognized, reported and analyzed. This is one of the most critical issue of many european hospitals. Regards, Matej

Dear dr.Tuhec

Thank you for your response and offer to cooperate in this for me a very interesting field! I fully agree with you that we should be more involved clinical farmacist and to closely cooperate with the first Clinical Pharmacology and, both of them closely with teams or wards where there are, of course, on a daily basis and help them with their correct aspect for transcription therapy! In this way, the multidisciplinary approach would be to reduce the possibility of polypharmacy or malpractice in terms, wrong prescribing!

Best Wishes

Jasenko Karamehic

Dear dr. Tuhec,

Being free to express my experience, how it is organized clinical pharmacy in the UK-London, Clinical Pharmacology Germany (Hamburg), where I worked as a visiting professor, a scholar in the UK Tempus European Union or the DAAD, the German government, and as such the user Fulbright scholarships USA- (Yale University and Buffalo Genneral Hospital-Western New York! I have also comments on the revision and improvement of teaching in the medical and pharmaceutical faculties in the area of clinical Pharmacy and clinical pharmacology, because at these faculties surrender for years and I think there is plenty of room for improvement!

As I announced in an earlier response, we'll pass their experiences with some of my visits abroad as a visiting professor in the field of clinical pharmacology and clinical pharmacy! From my answer is imposed and logical answer why it was not conducted in Eastern European countries where it belongs geographically and my country!

2000 years I spent as a guest of The School of Pharmacy University of London as the winner of the Tempus scholarship of the European Union.

I must say that the Faculty of Pharmacy fosters excellent cooperation with departments of clinical pharmacy in almost all major London's hospitals! I also have had the opportunity to stay in all eight major hospitals and learn about the work of clinical pharmacist, with their tasks and a description posla.The most of the time I with the help of fellow British pharmacists spent on classes for organ transplants that I and my primary interest as nefro transplant immunologist or pharmacologist!

Most of these hospitals are pharmacists with this renowned Faculty of Pharmacy, now working as clinical pharmacists after course completion of training in this area and maintain close cooperation with their faculty as insightful and scientific institution!

This is an example of  commend.Clinical pharmacist maintains direct cooperation and covers according to their interests and education of the close relationship and cooperation with various clinics and departments quite specialized! This means that a clinical pharmacist covers clinic or department, for heart disease, others for endocrine disorders, oncology third, fourth gynecology fifth surgery ... etc! This very successful work, clinical pharmacists and pharmacologists attends regular meetings with doctors practitioners go rounds and are consulted and respected by doctors and other medical staff! Closely involved with their advice, knowledge and experience in prescribing medication and avoiding unintended consequences of drugs and polypharmacy, which is the goal of this multidisciplinary approach, which is in my opinion this is completely justified! Why, this excellent system that is not in the countries of Eastern Europe and my country I'll soon be answered, or your opinion!

Dear dr. Matej Stuhec,

As I described the work in clinical farrmaceuta (UK-London) to a hospital in Great Britain, who is very very successful cooperating with clinicians in hospitals! This multidisciplinary team of doctors clinicians, clinical pharmacist and clinical pharmacologist is my opinion that the best and safest way to avoid polypharmacy and all the harmful consequences that arise from it, I think the malpractice of the unwanted effects of medicines as well as the financial effects are best when given timely the right medicine when he established diagnosis!

During my stay in Hamburg back in 1996 as a visiting professor used a DAAD Scholarship of the Government of Germany!

I spent a very useful time in Hospital Eppendorf in the department of clinical pharmacology! Then I saw that the Germans in everything well organized, and even twist the field! That's when I first saw that clinical pharmacologist distinguished German professor dr.Hasso  Scholz otherwise the head of this institution goes on rounds at the cardiology clinic and on an equal footing with clinicians argues that the best treatment given to the patient! It was an excellent experience and I learned a lot from these visits great Britain and Germany! The way in which the two countries have developed a clinical pharmacy and clinical farmakology  is the best way to exclude the malpractice of giving the wrong treatment or polypragmasy and, to a multidisciplinary approach in the treatment of patients!

What did I do after this knowledge in your own country and how I have tried to improve this area in a country in Southeast Europe to the next'll answer!

Regards Jasenko Karamehic

Dear dr. Stuhec,

Upon returning to my country, rather in the Faculty of Medicine Tuzla, as a professor of internal medicine-pharmacologist, I tried to convey my experience of stay in the UK and I Njemačkoj.odgojio several clinical pharmacologists who specialize in the area to which greater contact with doctors clinicians in UCC Tuzla! he's what I largely failed to give my positive experiences from the UK and Germany and that they bump in the course of specialization that must work closely with clinicians and work as a team multisciplinirarni! It should be discussed on a daily basis on the common consistent view on giving treatment to patients? Also in the transplant team 1999 years time where I was the coordinator Tuzla became part of the clinical pharmacist who helped me a lot in this great project!

Other modeled on Hamburg introduced a technology HPLC determination of drugs, which is what we used for the purposes transplantation of  kidney, determination of cyclosporin in the blood or other drugs, for example, antiepileptics, cardiotonics, etc.!

Both in any case significantly reduce and avoid  the possibility of polypharmacy!

In Tuzla, I lived and worked as a professor of pharmacology and as coordinator for starting transplants in the period 1993-2002 and for the period, one was a war periods in my country I did what I could in those difficult war and post-war circumstances! And I one more note transplants have successfully started 15.9.1999 and work to this day very successfully!

Regards

Jasenko

Dear Matej, dear Jasenko,

regarding renal transplantation.

I did my PhD thesis in renal transplantation, in the filed of pharmacogenetics and variability in tacrolimus exposure. I have to say it was great pleasure to work with clinicians at University Clinical Ceter in Nis, Serbia. Also, renal transplantation or any other solid organ transplantation is a real example of interprofessional cooperation and multidisciplinary work including internists-nephrologists, surgeons, biochemists, clinical pharmacologist and pharmacist. This kind of cooperation may reduce potential adverse effects and toxicity as well as provide better quality of life and longer graft and patient survival. Implementation of multidisciplinary based personalized therapy tailor for one particular patients, I think it's key factor in a field of transplantation. 

Our hope in the very short period of time, we could bring pharmacist next to the patients bed.

Best regards,

dear 

Dear Dr Stuhec and dear dr. Stefanovic,

Thanks for the compliments dear colleague Nikolic! Also I greet you well and learned dr.Stuhec. I'm very glad THAT YOU doctorate at the tacrolimus drug that is important and proved to be a better solution as the first choice in liver transplantation, which is grateful immune body to conduct the immunosuppression, as it is not strong antigen!

I long I do transplants, more than 1980 years of the last century, when I was working in a team in Sarajevo with Professor Momir Macanovića And Professor Sreten Bošković my big role models and teachers!  I did doktorate  the AKH in Vienna in the period of 1988-1992 years of Transplantation Immunology, related to the cytokines interleukin-as predictors of rejection! You have my CV  ON Reaserch Gate !

I will send you my resume that can orient my work!

I've written a lot of books and papers in this area organ transpntation and most of them can be found on my profiles among the list of papers and books on Reseach Gate in electronic form!

I stand at your disposal for any kind of communication from this for me is very interesting we field!

Nice regards once again  for You and dr.Stuhec

I  use your links for  send my CV  dear  dr.Stuhec for dr.Nikola Stefanovic

My  CV 

Biography

            Jasenko Karamehić was born on February 18, 1953 in Banovići. Attended Primary School and Gymnasium in Vareš. In 1977, he graduated at Medical Faculty, University of Sarajevo. In 1986, he completed specialisation in Internal medicine at Medical Faculty University of Sarajevo. Dr. Jasenko successfully completed subspecialization in Clinical Immunology in United States of America  (USA) and Germany (USA- Buffalo Hospital, New York State, USA in 1998 and Germany-Liebeck in 1999). Completed Clinical Pharmacology subspecialisation (Hamburg – Harburg, Germany in 1996). and (London, Great Britain, in 2000). In 2002, Dr. Jasenko completed Organ Transplantation and Transplantation Immunology subspecialisation in City of New Haven - Yale University, State of Connectictut (CT), USA In 2002/2003, Dr. Karamehic became stipendist of prestigious American government's  Fulbright scholarship, which he had spent at Yale School of Medicine Hospital (Ivy League, Yale University - USA).

In 1988, Dr. Jasenko Karamehić earned his Master’s degree at Medical Faculty, University of Sarajevo.

Dr. Karamehić earned his Ph.D. degree in Vienna (Austria), in period from 1988 to 1991, at Second University Internal Clinic from Transplantation immunology (AKH). Due to war in Bosnia and Herzegovina his Ph.D. dissertation was successfully defended in 1993 at Medical Faculty, University of Tuzla.

Dr. Jasenko became Head of Institute and Department of Pharmacology at Medical Faculty, University in Tuzla for the period 1993 - 2002. He was also Vice Rector for Science at University of Tuzla. Dr. Karamehić became Full time (tenured) Professor in two additional scientific-academic areas of Pharmacology and Toxicology with Clinical Immunology.

Until now, Dr. Karamehić, published like author or co-author 18 books and 242 scientific articles in addition to over 50 domestic and international projects. Dr. Jasenko wrote a book "Transplantation of Kidney" with eminent colleagues from Yale University (USA). Prof. Karamehić's book is displayed at two Ivy League's University libraries: Yale University's Harvey Cushing / John Hay Whitney Medical library in City of New Haven, State of Connecticut, USA, in 2005 and Harvard University's Francis A. Countway Medical library Cambridge and Boston, Massachusetts, USA in 2010.

Pioneer of after war kidney transplantation in Bosnia and Herzegovina. Introduced transplantational immunology and monitoring of immunosupresive drugs into Clinical Centres in Bosnia and Herzegovina (UKC Tuzla and UKC Sarajevo). Dr. Jasenko has been teaching at numerous prestigious world's Universities (Austria, Great Britain, Germany and USA). Founder and Head of Institute for Clinical Immunology at University Clinical Center (UKC) Sarajevo and First President of Association of  Immunologists in Bosnia and Herzegovina.

Best Regards Jasenko

Extraordinary career life.

Thanks a lot!

Best Regards

Jasenko

Dear colleagues  dr.Stefanovic,

I am at your disposition to cooperate with you no matter what you're interested in literature than to specific questions from the menu very complex but at the same time very dear to me and interesting we field!

Hi to everyone,

I agree with Nikola, very respectful CV. In addition, our health systems were almost equal 25 years ago, however now there are similar in some ways and also different in many ways. Especially what i am very pround we have established settings of clinical pharmacists in each slovenian primary community health setting, which has not been seen in Europe, except UK!

Hospitals are another story, we have also established a new law, where clinical pharmacy should be on the ward at each hospital setting. At the moment we are still in a lack of clinical pharmacist specialists in Slovenia, although we have 60-70 specialists and those who ll finish it in near future. The best approach is to add a clinical pharmacist next to the patients' beds, where in healthcare team he can suggest drugs to attending physicians and of course measure and monitore clinical outcomes. This step is a key step. Another story is reporting of medical errors in hospitals, where clinical pharmacist should analyse, report medical errors and establish appropriate communication within each hospital.

See our new law below. It is in slovene language, however you ll understand the key points. articles N: 62., 63., 6.

If the countries have been established clinical pharmacologists it is another story how to cooperate with clinical pharmacist. There are many differences between those profile, especially a knowledge of epidemiology, pharmacoepidemiology, meta-analyses and evidence based treatment, pharmaceutical care, which are supported by clinical pharmacy. Clinical pharmacologists have better knowledge of etiology of diseases, basic pharmacology probably etc. Hospital admission, omission and transition (pharmacotherapy) should be checked by appropriate well teached clinical pharmacist. In Slovenia we do not have a specialization from clinical pharmacology and therefore we are dealing with these problems (clinical pharmacists). For the next European Congress of General Practitioners we have established a workshop where we ll show what clinical pharmacists can help GPs in real clinical practice with clinical cases.

Regards,

Matej

-

https://www.uradni-list.si/_pdf/2016/Ur/u2016085.pdf

Dear dr.Stuhec,

Thanks for the compliment! I need you and you congratulated on a very high level RG score and it is my great honor to have with you correspondence!

Carefully I read your comment and has to to know the following:

You have a very good system of organization of clinical pharmacy!

That's what you describe reminds me strongly on the UK where well-developed clinical pharmacy perhaps the best in Europe!

I see that you have a system by accident and I welcome and congratulations on that!

 Slovenia has always been a leader in the former state, I see that it is I stayed!

What I am a little surprising that you do not have more specialization in clinical pharmacology !?

Why?

 I  spent more than 20 years, 15 days at the Institute of Pharmacology of the Faculty of Medicine 1995 years while the boss was imported prof.dr.Metka Budihna with whom I worked very well together!

 I think I have places I need for both specialized and Clinical Pharmacy and Clinical Pharmacology

! Why?

 I think you are the gave the  best answer to give when you write the specifics of both specialization!

 See to die in those similar but I have a large and diversity and that the complement each other and just as these constitute a whole course with the patient's bedside and work closely with doctors practitioners!

Best Regards

Jasenko Karamehic

I'm particularly interested in your opinion and dr.Stefanovica (if this is read) about the role of clinical pharmacologists together in a team with clinical pharmacists and doctors practitioners in a hospital ward?

Hi,

Yes absolutely if there are clinical pharmacologists available in the country they should be included in the healthcare proffesional team on the ward. They should discuss about the main treatment goals and establish appropriate scales to measure the most important outcomes. Absolutely I am for collaboration in this team, although limitations of each profile should be described before starting to avoid serious problems in communication. What i wanted to say... is that clinical pharmacy should be within this team only on the ward (there is not possible to do clinical pharmacy outside of the ward in the appropriate level). Another story is prescribing... somewhere clinical pharmacologists /pharmacists can prescribe medications (UK, Ireland, USA) and therefore this step should be done according to collaboration agreement between professionals (example USA). This formal agreement is very important for patients safety. The most important thing to collaborate between clinical pharmacist and pharmacologist is to accept different benefits and limitations of both profiles in a very professional way. They can also divide some actions. Pharmacoeconomics, medication reconciliation, drug history, admission and omission (discharge) consultation as part of pharmaceutical care should be included in daily work of clinical pharmacist. Pharmacologists (if can prescribe) then can prescribe medications in a collaboration with clinical pharmacist and attending physician. Often pharmacologist is better supported by etiology of disease and clinical implications. To sum up, the most important is to discuss about patients symptoms, improvements etc... on daily basis on the ward according to evidence-based medicine.

Regards,

Matej

https://www.ncbi.nlm.nih.gov/books/NBK2637/

Sorry that i forgot to answer on your question dr. Karamehic and thanks to recognize my score.

About clinical pharmacology specialization in Slovenia ... At the moment we have only some specialists from basic pharmacology (also from Serbia and another countries) within our system (maybe 5,7 etc.. very few) but we do not have specialization from clinical pharmacology. This is a big difference, because basic pharmacology could be far away from clinical outcomes optimization and outcomes measuring, which is the main goal of clinical pharmacy (and also clinical pharmacology). Economic outcomes (via cost-effectiveness analysis) and evidence-based medicine are extra sciences supported by clinical pharmacy. Basic pharmacology is drug-oriented science (e.g. difference between drug efficacy and drug effectiveness is a colorful example or Emax/ED and real clinical outcome according to NNT/guidelines/meta-analyses). If we want to do in real clinical practice we should be supported by well-designed meta-analysis and be close to network-meta-analysis.

Pharmacoeconomics, medication reconciliation, drug history, admission and omission (discharge) consultation as part of pharmaceutical care are now adopted as part of work of clinical pharmacist in Slovenia. We have more than 50 clinical pharmacists within the system (not in all hospitals but in the majority of them). Many of them are also included in daily rounding, some of them work only consultation (pharmacotherapy review done by attending physician request). Anyway we still have problems on some points, especially with a lack of clinical pharmacists within the hospitals. Why we do not have a specialization from clinical pharmacology i really do not know, because clinical pharmacologists are primarily physicians, on the another side we are pharmacists.

I should say we are quite recognized in Slovenia, especially among physicians. There is almost no medical congress where at least one clinical pharmacist is invited speaker (e.g. SLO congress of Psychiatry, Internal Medicine, Dermatology etc ...). But we moved this field of pharmacy up in the last 10 years. What is very important is to be recognized within medical journals as reviewers and first/corresponding author as clinical pharmacist (see my publons profile below for example), which give us an extra recognition, which can not be ignored. For example i have reviewed many papers for SCI journals for ADHD, bipolar disorder, MDD, which are primarily psychiatric topics, however well-teached clinical pharmacy from upgrade from mental health, can also deal with these problems.

Regards,

Matej

https://publons.com/author/460522/matej-stuhec#profile

Dear dr. Stuhec,

Thanks to the detailed and well documented answer!

I will soon give its opinion not only for the former Yugoslav, but much wider, because I spent many years in Western Europe, North America and Asia far ..... where I am lived and worked ...!

Regards

Jasenko Karamehic

am

As a long-time teacher at the university, among other things, and to pharmaceutical colleges in the country and abroad, thinking that it must curriculum, the curriculum changed in favor of clinical cases where the subject of the paper is patient and bed, especially on program Content- curriculum specialization in clinical pharmacy, which must be with more items and time with the patient's bed or to improve cooperation with the doctors who lead the patient directly and be part of this team, which unfortunately is not the case!

On the program Content- curriculum specialization in clinical pharmacy, which should be with more objects and time with the patient's bed or to improve cooperation with the doctors who lead directly to the patient and be part of this team, which unfortunately is not the case!

It is best developed in Europe in the UK and I can see that you are in Slovenia made great progress in this area to what I sincerely congratulate you!

If you read the esteemed Dr. Stefanovic this my opinion I'm interested how it solved in Serbia!

Greetings from Sarajevo

Jasenko

Predložite izmjenu

Dear Dr. Karamehic,

I agree with you. The basic thing is to move clinical pharmacy from the pharmacy to the patients' beds within healthcare team on the ward in all clinical activities (e.g. medication reconciliation, medication history, drug suggestion, drug monitoring, TDM, outcome measuring, drug consultation at discharges etc ...). It means that clinical pharmacy converted from supplier to provider. It is not easy step, because all healthcare professionals should respect clinical pharmacy as indispensable part of healthcare team on the ward.

Second important thing is to receive and get enough space in healthcare programs of government! You should have also political support, as has been seen in California during 80's when they get a prescribing rights from the Californian government! After that they established appropriate law to get clinical pharmacists these authorities.

Thirdly, you should use these stories and documents and law within systems. It means to say... OK now clinical pharmacist should be next to the patients, how to report reports, which way, how to make pharmaceutical care, how to dokument etc ... Many practical problems could be developed, which can lead to conflicts if they are not supported by head of program (director, panel etc...).

What is also very important is to teach clinical pharmacists about epidemiology, pharmacoepidemiology, psychopathology, clinical outcomes, statistics, clinical trials, pharmacy practice and of course evidence-based pharmacotherapy.

We are on the way to move up .... we did many things in Slovenia but still we have to move more clinical pharmacists to the hospitals, where pharmaceutical care should be provided to each patient.

Regards to Sarajevo!

Matej

Dear dr. Stuhec,

Thank you very much for your detailed and very documented response!

In a very short time in correspondence with you for me it was very helpful because I learned a lot from you good things about the role of clinical pharmacists in modern science today!

No wonder you have such a high RG imminent-score, to what you I once again congratulate!

The right is my great pleasure to have scientific communication with you respected dr.Stuhec

Hello Regards  my dear Dezelu and  Ljubljana

Jasenko

Predložite izmjenu

Dear dr. Karamehic,

No problem. There are many differences between systems. I think we had similar system within ex-country so implemetations of these results could be appropriate approach in these countries.

Thanks again to approve my RG score, mostly from published articles from clinical pharmacy practice and important implementations of that system in real clinical practice. I am glad to hear You dr. Karamehic. If You have any remark/question about clinical pharmacy do not hesitate to contact me back.

Regards to Sarajevo,

Matej

Dear dr.Stuhec,

Thank you once again on this very documented analytical savvy factual answers!

Without false courtesy, I repeat once again, a lot of you I learned useful information on clinical pharmacy, which made me very interested because I am a professor of clinical pharmacology and these are fully compatible areas that complement each other!

Of course you have the characteristics and peculiarities that you, in a letter to your very well expose!

It is a pleasure much with you in the future to keep correspondence and exchange opinions because we do similar but different areas of clinical pharmacy and clinical pharmacology!

Regards Me exceptional dear land of Ljubljana and from this morning very cold Sarajevo!

With great respect and reverence

Jasenko Karamehic

Dear dr.Stuhec,

and to conclude his answer on Your Very interesatno basic question!

As I suggested curriculum reform pharmaceutical faculties also needs reform curriculum of medical schools in the area of study of pharmacology and clinical pharmacology, that percentage should be much more present than ever before!

Because after all, a medical student, tomorrow when he graduated though it's the basic subject of work a patient!

Now more studies the basic pharmacology and general, very little clinical pharmacology!

Is that the reason that dominate the general -bazicni pharmacologists but, there is not enough clinical pharmacologist! Perhaps, this may be the reason !?

In our region but in the world and still dominates the basic pharmacology, in relation to clinical!

The attitude in the classroom by me should be 30-40% of the general pharmacology and the rest should be clinical!

That would be my suggestion I also kept and organized classes in farmakologijeu a ratio!

As much as I really pleasantly surprised by progress of clinical pharmacy, so I am surprised that there is no general specialization in clinical pharmacology, so I'm you I understood, because I was the last time biou Ljubljana 15 days back in 1995, with imported prof.dr.Metke Budihna (with whom I have had excellent cooperation) .No know much about Serbia, I know a bit more about Croatia, but not much!

In Bosnia I speak of the Federation of Bosnia and Herzegovina has a specialization in clinical pharmacology, but I think our clinical pharmacologists need to go on rounds with doctors practitioners in medical consultations, the medical colleges but as far as I know they do not work! Therefore, I can not fight a status objectively belongs!

In other words, only a well-educated pharmacist and pharmacologist in clinical pharmacy and pharmacology can be team together with Dr. clinicians closely related and have a guarantee that they only contain a minimum of the minimum errors in prescribing and giving treatment of patients so-called "drug malpractice"!

Best Regards for Dezelu

Jasenko Kramehic

Dear dr. Karamehic,

i agree with you, a basic pharmacology is smth miles away from real clinical pharmacology. Sample example is difference between drug efficacy and drug effectiveness. In my point of view faculty of medicine and pharmacy should cooperate to establish appropriate specialities in real clinical practice (e.g. clinical pharmacy and pharmacology). Without patients' charts, rounding, patient consulting and involving in drug choosing, monitoring etc it is impossible to do clinical pharmacy.

Often we have many opponents of these clinical important science (also I have had in my practice), who think that this service is not important. However, if they respect evidence-based medicine they should support it, because for involving of clinical pharmacy service we have the strongest evidence Ia. If we respect it when conducting guidelines, then we should respect it in this way to accept not refuse this particulary one of the most beneficial service for our patients. Network for Excellence in Health Innovation sad that clnical pharmacy service in daily rounding on the ward is the most effective approach to reduce medical erros (at least 50 %). They cover more than 10 US hospitals. Consequently, if we want really reduce medical errors then we must educate and put clinical pharmacists on the ward in all activities connected with pharmacotherapy.

Regards,

Matej

http://www.nehi.net/bendthecurve/sup/documents/Medication_Errors_%20Brief.pdf

Dear dr.Stuhec,

Absolutely agree with you and your opinion!

But I am an optimist and a great worker and I fighter, you must fight these obstruction and opponents, there is no way around it!

Soon I'll get back to you I explained even though I had all the professional and scientific references why I failed a lot more to develop the discipline of which we speak in our correspondence!

Best Wishes

Jasenko

Dear Dr. Stuhec,

I thought you read more letters on this and then I gave up when I once read you answer me!

Practically it is more or less the same situation in the countries of former Yugoslavia, is a policy which has dominated in all but unfortunately I in science!

It is more important to be a member of a political and, especially the ruling party, but get the highest honors in science ....! Simply teaching in this area is being dominated by political parties last 20-25 years and their exponents colleagues that this is the only reference because the moral politically similar, even though they have modest CV, they are the ones who decide about everything and I about my and your fate ....

Despite everything, we will persevere to deal with and develop our discipline on the case Clinical Pharmacy and Clinical Pharmacology, because we love it and we are motivated to deal with it, while others may be involved in politics and "meddling" I still have these electronic databases that accurately Mathematics (RG score) show where when in the world, but we do not have here what is ashamed even on the contrary, we can be proud of our work and our achievements ... ..!

Apology to you that I took Your opinion that we're like-minded, but I think it is at least my opinion is such after this communication to you I only have great respect and appreciation to you personally and in your work with the results that are impressive, I think the total you CV or And to you RG outstanding score ... .. to whom I offer you a sincere high recognition ....

Greeting

Jasenko

Dear dr.Stuhec,

I am sending you a possibility to use three of my books that are in electronic form in my bibliography that prilozenana ReaserchGate!

All three were written in Bosnian-Croatian-Serbian language so you can easily use it!

When you have clinically farmacist and work every day in practice, I think you can use them as

Tertiary field, in which we have very little literature looking at the global scale ....!

I give them individually because I have a lot to each of them invested power, work and time I think I deserve individual references!

You can also view other books relating to organ transplantation, transplant immunology and monitoring protocols and immunosuppressive therapy! It was attended by me and a great number of American colleagues from Yale School of Medicine, New Haven - CT, USA) and Harvard University, Boston , Massachusetts!

You have very well-developed organ transplant I would ask that they possibly tell a fellow at the department for transplantation in Ljubljana and Slovenia in general!

Thank you in advance with a nice compliments

Jasenko

Dear colleagues dr. Stuhec ,

Also, and this my book entitled

  "The use of drugs in nephrology, dialysis and kidney transplantation," issued in 2002 years!

author Jasenko Karamehic

You have the in this book describes a large number of drugs (250) arranged in alphabetical order of their pharmacokinetics and pharmacodynamics, Adverse reactions of drugs that we used in kidney transplantation,, nephrology, immunosuppressive therapy protocols or kidney.

 I think a lot can aid in education as well as teams of doctors who sye prepare for a kidney transplant!

The book is supplied in electronic form in my bibliography on my side on Reaserch Gate.

Best Wishes

Jasenko

Dear colleagues dr.Stuhec

In my book titled authors Jasenko Karamehic and associates

"Transplants Kidney and Pancreas Clinical and immunological aspects of pharmacotherapy" issued in 2012 years:

You can also use the book in addition to this section as it relates to the issue of organ donation, ethical and legal issues questions, monitoring and protocol immunosuppressive ,adverse reaction of drugs, general guidelines for transplant patients, economic analysis of costs and transplantation of organs and federation entity of Bosnia and Herzegovina!

All this can be used to create legislation for the law on organ transplants in your country as textbooks even for teaching students at medical schools!

The book is supplied in electronic form in my bibliography page on Reaserch Gate.

Regards

Jasenko

Dear colleagues dr. Stuhec,

Also, and this my book entitled The immunosuppressive therapy and its use in organ transplants "issued 2012 years!

author Jasenko Karamehic, Sebija Izetbegovic and Associates

you have the answers to questions donations, ethical and legal issue in organ transplantation, Monitoring and protocol immunosuppressive therapy adverse reactions of drugs, protocols or kidney and relates to your interest in the legal and educational process in this area!

The book is supplied in electronic form in my bibliography on my side on Reaserch Gate.

Best Wishes

Jasenko

Carefully reading the comments from colleagues, after a certain time, I would include in the discussion, only one comment that the problems in this area authorities in all these countries the same as it had the same political and social system that is both produced and disturbed system in health and medicine, general irresponsibility, however, this largely applies to your question!

Perhaps smaller exceptions are Slovenia, Czech Republic and Slovakia!

Regards

Jasenko Karamehic

Why many Eastern European countries did not establish clinical pharmacy service in the hospitals next to the patients? Who will deal with errors?? - ResearchGate. 

All the more the time is spent, the thoughts I have made the most of the thesis I have made is entirely meaningful to the countries your issue is concerned, excluding these three countries whose social systems are much more advanced and more similar to the developed democracies in the west of my country and others in the circle Where there is simply no application of the legal state, and therefore the introduction of clinical pharmacy in hospitals which in my view is a predictor of the social development and progress of a country!